Documentation

The note is the record, not the form.

Most software treats a session note as a text box that saves. It is a clinical and legal document, and the difference shows the day somebody asks what it said a year ago.

Signing

A signed note stops being editable

Signing stamps who signed it and the credential they held at that moment — read from their record and frozen onto the note, so a later promotion cannot rewrite what a past signature said.

Correction

Additions, never rewrites

A locked note that turns out to be wrong is corrected by an addendum: new content, its own author and its own signature, appended without moving a word of the original. The record keeps saying what it said, and what was added is visible alongside it.

Supervision

Co-signed by the supervisor of record

A pre-licensed clinician's note waits for their supervisor, and the supervisor is resolved as of the date of service — so a note from March is co-signed by whoever supervised in March, not by whoever supervises today.

Disagreement

A supervisor returns it, never rewrites it

A supervisor who thinks the documentation is wrong sends it back with a reason, and the author corrects it in their own words. A supervisor editing somebody else's clinical account and then attesting to it would make the signature meaningless.

Separation

Psychotherapy notes answer to their author

Kept in their own store, with their own access rules and their own audit trail. The clinician who wrote one can open it beside the session it belongs to; everybody else, the practice owner included, sees only that it exists. It is never in an export. §164.508 treats these differently, so the product does too.

A correction that leaves the original standing.

A locked note that turns out to be wrong is not edited. The addition is its own record, with its own author and its own signature, appended without moving a word of what was signed.

Notes

Owed Signed To co-sign

Chart A. Whitlock

Progress note Aug 17, 2026 · 50 min Signed & locked

R. Okafor, LMHC · signed Aug 17, 2026, 6:12 PM

Addendum Added Aug 24, 2026

R. Okafor, LMHC · signed Aug 24, 2026, 11:40 AM

Two signatures, two dates, and nothing overwritten — so a year later the record still says what it said, and what was added is visible beside it.

Supervision that survives somebody leaving.

Supervision here is time-bounded rather than a pointer at whoever is currently assigned. A supervisor who took over in June cannot attest to a March session they never oversaw, and one who leaves does not take the record of what they signed with them.

How the record is protected

The treatment plan

A plan that says whether anything moved.

Most treatment plans are a form completed at intake and never opened again. This one has three parts and a fourth thing that happens to it afterwards, and the fourth is what makes the first three worth filling in.

The goal is what the client is aiming at: In their words where possible — the product's own example is "sleep through the night most nights". A goal written in clinical language is a goal the person it belongs to cannot check themselves against.
The objective is what makes it measurable: A target and a date. This is the part a payer audit looks for, and the reason is not bureaucratic: a goal with no measurable objective cannot be shown to have been met or missed, so it cannot be worked towards.
The intervention is what the clinician will do: Exposure and response prevention, behavioural activation, psychoeducation about the panic cycle. A method, recorded as its own thing rather than left as prose in a box, so a plan says how as well as what.
And then it gets rated, session by session: A clinician rates a goal at a session, and those ratings accumulate. That is the difference between a plan filed at intake and a document that can answer whether the work is going anywhere.

Revising a plan writes a new version rather than editing the old one, and the goals are copied forward. A superseded version keeps the goals it was signed with — because what somebody agreed to in March is a different question from what the plan says today, and both get asked.

The rest of it

Start with the week you are already having.

Set up a practice, put a real week in the calendar, and see whether it fits before you move anything across.

Start free Read the documentation